{Insert provider contact information here} Notice of Medicare Non-Coverage {insert effective date}

{Insert provider contact information here}
Notice of Medicare Non-Coverage
Patient name:
Patient number:
The Effective Date Coverage of Your Current {insert type}
Services Will End: {insert effective date}
Your Medicare health plan and/or provider have determined that Medicare
probably will not pay for your current {insert type} services after the effective
date indicated above.
You may have to pay for any services you receive after the above date.
Your Right to Appeal This Decision
You have the right to an immediate, independent medical review (appeal) of the
decision to end Medicare coverage of these services. Your services will continue
during the appeal.
If you choose to appeal, the independent reviewer will ask for your opinion. The
reviewer also will look at your medical records and/or other relevant information.
You do not have to prepare anything in writing, but you have the right to do so if
you wish.
If you choose to appeal, you and the independent reviewer will each receive a
copy of the detailed explanation about why your coverage for services should not
continue. You will receive this detailed notice only after you request an appeal.
If you choose to appeal, and the independent reviewer agrees services should no
longer be covered after the effective date indicated above, neither Medicare nor
your plan will pay for these services after that date.
If you stop services no later than the effective date indicated above, you will avoid
financial liability.
How to Ask For an Immediate Appeal
You must make your request to your Quality Improvement Organization (also
known as a QIO). A QIO is the independent reviewer authorized by Medicare to
review the decision to end these services.
Your request for an immediate appeal should be made as soon as possible, but no
later than noon of the day before the effective date indicated above.
The QIO will notify you of its decision as soon as possible, generally no later than
the effective date of this notice.
Call your QIO at: {insert name and number of QIO} to appeal, or if you have
See the back of this notice for more information.
Form CMS 10095-NOMNC (Exp. 10/31/2013)
OMB approval 0938-0910
Other Appeal Rights:
If you miss the deadline for requesting an immediate appeal with the QIO, you still
may request an expedited appeal from your Medicare Health plan. If your request
does not meet the criteria for an expedited review, your plan will review the decision
under its rules for standard appeals. Please see your Evidence of Coverage for more
Contact your plan or 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048
for more information about the appeals process.
Plan Contact Information:
Additional Information (Optional):
Please sign below to indicate you have received this notice.
I have been notified that coverage of my services will end on the effective date indicated on
this notice and that I may appeal this decision by contacting my QIO.
Signature of Patient or Representative
Form CMS 10095-NOMNC (Exp. 10/31/2013)
OMB approval 0938-0910